Reports From the Field

Implementation of a Patient Blood Management Program in a Large, Diverse Multi-Hospital System

Journal of Clinical Outcomes Management. 2020 May;27(3):123-129 | 10.12788/jcom.0009

Author(s):

Sumita Markan-Aurora, MD

Rachel Miller, MSN, RN

Audrey A. Gronemeyer, MPH

Jennifer S. Kempf, MS

Bruce L. Hall, MD, PhD, MBA

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References

1. Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: A clinical practice guideline from the AABB*. Ann Intern Med. 2012;157:49-58.

2. Goodnough LT, Levy JH, Murphy MF. Concepts of blood transfusion in adults. Lancet. 2013;381:1845-1854.

3. Hébert PC, Carson JL. Transfusion threshold of 7 g per deciliter—The new normal. N Engl J Med. 2014;371:1459-1461.

4. Gani F, Cerullo M, Ejaz A, et al. Implementation of a blood management program at a tertiary care hospital: Effect on transfusion practices and clinical outcomes among patients undergoing surgery. Ann Surg. 2019;269:1073-1079.

5. Podlasek SJ, Thakkar RN, Rotello LC, et al. Implementing a “why give 2 when 1 will do?” Choosing Wisely campaign. Transfusion. 2016;56:2164.

6. Boral LI, Bernard A, Hjorth T, et al. How do I implement a more restrictive transfusion trigger of hemoglobin level of 7 g/dL at my hospital? Transfusion. 2015;55:937-945.

7. Geissler RG, Kosters C, Franz D, et al. Utilization of blood components in trauma surgery: A single-center, retrospective analysis before and after the implementation of an educative PBM initiative. Transfuse Med Hemother. 2015;42:83-89.

8. Goel R, Cushing MM, Tobian AA. Pediatric patient blood management programs: Not just transfusing little adults. Transfus Med Rev. 2016;30:235-241.

9. Gupta PB, DeMario VM, Amin RM, et al. Patient blood management program improves blood use and clinical outcomes in orthopedic surgery. Anesthesiology. 2018;129;1082-1091.

10. Leahy MF, Roberts H, Mukhtar SA, et al. A pragmatic approach to embedding patient blood management in a tertiary hospital. Transfusion. 2014;54:1133-1145.

11. Leahy MF, Hofmann A, Towler S, et al. Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: A retrospective observational study in four major adult tertiary-care hospitals. Transfusion. 2017;57:1347-1358.

12. Meybohm P, Herrmann E, Steinbicker AU, et al. Patient blood management is associated with a substantial reduction of red blood cell utilization and safe for patient’s outcome: A prospective, multicenter cohort study with a noninferiority design. Ann Surg. 2016;264:203-211.

13. Morgan PN, Coleman PL, Martinez-Garduno CM, et al. Implementation of a patient blood management program in an Australian private hospital orthopedic unit. J Blood Med. 2018;9;83-90.

14. Norgaard A, Stensballe J, de Lichtenberg TH, et al. Three-year follow-up of implementation of evidence-based transfusion practice in a tertiary hospital. Vox Sang. 2017;112:229-239.

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16. Oliver JC, Griffin RL, Hannon T, Marques MB. The success of our patient blood management program depended on an institution-wide change in transfusion practices. Transfusion. 2014;54:2617-2624.

17. Thakkar RN, Lee KH, Ness PM, et al. Relative impact of a patient blood management program on utilization of all three major blood components. Transfusion. 2016;56:2212-2220.

18. Yang WW, Thakkar RN, Gehrie EA, et al. Single-unit transfusions and hemoglobin trigger: relative impact on red cell utilization. Transfusion. 2017;57:1163-1170.

19. Frank SM, Thakkar RN, Podlasek SJ, et al. Implementing a health system-wide patient blood management program with a clinical community approach. Anesthesiology. 2017;127;754-764.

20. Verdecchia NM, Wisniewski MK, Waters JH, et al. Changes in blood product utilization in a seven-hospital system after the implementation of a patient blood management program: A 9-year follow-up. Hematology. 2016;21:490-499.

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From BJC HealthCare, St. Louis, MO.

Abstract

Background: There is limited literature relating to patient blood management (PBM) programs in large multi-hospital systems or addressing challenges of implementation across diverse systems comprised of community and academic hospitals.

Objective: To establish a PBM program to improve utilization of blood transfusion units at a multi-hospital system in the Midwest (BJC HealthCare).

Methods: High-impact strategies in establishing the PBM program included formation of Clinical Expert Councils (CECs) of providers, establishment of consensus utilization guidelines, and development of a robust reporting tool. CECs enabled collaboration and facilitated standardization across a complex system of academic, private practice, and tertiary facilities with a diverse community of medical providers. Consensus guidelines and the PBM reporting tool were key to creating meaningful reports to drive provider practice change.

Results: Over the 5 years following implementation of the PBM program, there has been a steady decrease in red blood cell (RBC) utilization. Noticeable changes have taken place at individual hospitals in the system, including reductions in transfusions falling outside guideline parameters from 300 per quarter to less than 8 per quarter at 1 of our community hospitals. No negative impact on patient care has been identified.

Conclusion: In response to current transfusion guidelines and the need for optimizing stewardship of blood product resources, this hospital system successfully implemented a robust PBM program that engaged academic and non-academic community providers and decreased utilization of blood transfusion resources in line with consensus guidelines.

Keywords: quality improvement; RBC transfusion; transfusion practices; provider practice change; utilization trends.

Evidence from clinical trials and published clinical guidelines support the adoption of a restrictive blood transfusion approach in hospitalized, stable patients as best practice.^1-5 As such, the development and implementation of patient blood management (PBM) programs has become an increasingly important process improvement for reducing variability in transfusion practices and clinical outcomes.

As recently as 2013, BJC HealthCare, a multi-hospital system in the Midwest, had no standardized, system-wide blood management program, and transfusion practices varied widely across providers and between individual hospitals based on size, patient population, and resources. The system consisted of 13 hospitals, ranging from large tertiary to smaller community and academic hospitals. Although adults constituted the vast majority of the patient population, the hospital system also included a pediatric specialty hospital, St. Louis Children’s Hospital. In addition, some sites were staffed by private practice providers and others by university-based providers, including blood bank medical directors. Due to the diversity of settings and populations, efforts to align transfusion and other practices often faced multiple challenges. However, improving the management of blood transfusions was identified as a key resource stewardship priority in 2013, and implementation of a system-wide program began after extensive discussions and consensus approval by senior hospital system and medical leadership. The primary aim of the program was to optimize overall blood product resource stewardship. Specifically, we sought to control or reduce costs per patient-care episode using strategies that would not negatively impact patient care and could potentially even improve patient outcomes (eg, by avoiding unnecessary transfusions and their attendant risks).

There is a plethora of literature related to the implemention of PBM programs in individual hospitals,^6-18 but few reports specifically relate to large multi-hospital health systems,^19-21 or directly address the unique challenges of implementation across a diverse system of community and academic hospitals and providers.¹⁹Here, we discuss our experience with establishing a PBM program in a large, diverse, multi-hospital health system, provide examples of innovative strategies, and address challenges faced and lessons learned. Future endeavors of the PBM program at BJC HealthCare are also described.